AIM: To present an analysis of the surgical and perioperative complications in a series of seventy-five right hepatectomies for living-donation (RHLD) performed in our center.

METHODS: From January 2002 to September 2007, we performed 75 RHLD, defined as removal of a portion of the liver corresponding to Couinaud segments 5-8, in order to obtain a graft for adult to adult living-related liver transplantation (ALRLT). Surgical complications were stratified according to the most recent version of the Clavien classification of postoperative surgical complications. The perioperative period was defined as within 90 d of surgery.

RESULTS: No living donor mortality was present in this series, no donor operation was aborted and no donors received any blood transfusion. Twenty-three (30.6%) living donors presented one or more episodes of complication in the perioperative period. Seven patients (9.33%) out of 75 developed biliary complications, which were the most common complications in our series.

CONCLUSION: The need to define, categorize and record complications when healthy individuals, such as living donors, undergo a major surgical procedure, such as a right hepatectomy, reflects the need for prompt and detailed reports of complications arising in this particular category of patient. Perioperative complications and post resection liver regeneration are not influenced by anatomic variations or patient demographic.

Lortat-Jacob reported the first anatomic right hepatec-tomy in 1952[1]. Since then, and particularly in the past two decades, hepatic surgery has achieved important technical breakthroughs, such as intermittent portal triad clamping, total vascular exclusion, preoperative portal vein embolization with two-stage hepatectomy, and sophisticated methods of parenchymal transection.

An increased interest in the outcomes of right hepatectomy for adult to adult living-related liver transplantation (ALRLT) has likely contributed to these breakthroughs[2].

Although surgical techniques of excellence and major improvements in perioperative management are now a reality in referral centers for liver surgery, there are still several issues that make this major surgical procedure extremely worrisome when performed in healthy individuals, such as living donors.

In particular, there is still no definite consensus regarding the amount of liver that can be safely resected[3], a crucial point for the recipient and perhaps more important for the healthy donor.

Recent studies have emphasized that in living-related liver transplantation, results and survival appear to correlate with stratification in the volume of the liver allograft transplanted, expressed either as a graft-to-body weight ratio or as a percentage of the standard liver volume of the recipient[4].

Clearly, living-related liver transplantation (LRLT) represents the natural evolution of other surgical procedures, namely reduced-size liver transplantation and split-liver transplantation[5], and is based on the segmental anatomy of the liver and on its peculiar capacity to regenerate.

This procedure represents a major challenge for the centers involved, though it has been widely reported that it is a valuable option for decreasing mortality rates and drop out from waiting lists[67].

However, potential risk for the donor makes this procedure unique, and when complications in the healthy donor arise, the implications for the medical community are potentially devastating[8]. A recent systematic review[9] that focused on adult donor outcomes concluded that there are small but real risks when using the right lobe for living donors, though it also claimed that nearly all donors returned to normal function within 6 mo. Moreover, due to the short history of ALRLT, the long-term risks for the living donor are still largely unknown.

Numerous single-institution series have reported their complications for liver living-related donors[10–15] and a recent large study from the U.S. reported an analysis of administrative data on a group of 433 right- and left-lobe living donors identified as those at risk for perioperative complications[16].

The ethical debate over the potential risk to the donor[17] renders this field of surgery controversial and, as a result, we believe, worthy of reports on all single center experiences.

The aim of this study is, in fact, to present an analysis of the surgical and perioperative complications in a series of seventy-five consecutive right hepatectomies for living related liver transplantation (RHLD) performed in our center.

From January 2002 to September 2007, we performed 75 RHLD, defined as removal of a portion of liver corresponding to Couinaud segments 5-8, in order to obtain a graft for ALRLT. Two left-hepatectomies, corresponding to Couinaud segments 2-4, were performed for the same purpose during the initial phase of our experience, but are not reported in this study. The number of cases per year has been progressively increasing, with a peak reached in 2006, when 24 RHLD were performed. The trend has continued through this year (2007), with 17 RHLD performed so far. ALRLT represented the 20% of our total liver transplant activity over the last 2 years.

None of patients manifested any complications from pre-operative liver biopsy.

No living donor mortality was present in this series. No donor operation was aborted and no donors received any blood transfusion.

After the first 9 cases, we started to reinfuse the blood aspirated during surgery with the Cell Saver System (median: 250 mL; min: 0; max 1680).

Length of surgery, length of stay in the ICU, and total hospitalization are reported in Table 1, while all complications, codified according to the Clavien system, and their management, are reported in Table 2.

Twenty-three (30.6%) living donors presented one or more episodes of complication in the perioperative period. All these complications were resolved within the perioperative period.

Two donors (I.D. 1 and 12) had a small re-laparotomy because the intra-abdominal drain could not be removed.

One donor (I.D. 6) experienced a transient partial portal vein thrombosis, asymptomatically detected by ultrasound and completely resolved with low molecular heparin.

Two donors (I.D. 17 and 18) developed complications graded IV by the Clavien system. They were both admitted to the ICU: in one case for monitoring of an acute pancreatitis following an endoscopic retrograde cholangio-pancreatography (ERCP) performed because of a biliary leak, and in the second case for monitoring of a pulmonary embolism with no cardiac derangements.

Five patients (I.D. 13, 14, 17, 20, 21) presented complications that required multiple treatments: i.e. percutaneous drainage and stent placement.

Two patients (I.D. 19 and 21) presented two discrete, unrelated complications each: pleural effusion plus intra abdominal collection in one case and pleural effusion plus biliary leak in the other case.

Seven patients (9.33%) (I.D. 5, 9, 13, 14, 17, 20, 21) out of 75 developed biliary complications, which were the most common complications in our series. However, all of them were successfully treated by interventional procedures with removal of all stents or catheters within 6 mo from surgery.

CT-scan-calculated donor mean total liver volume, mean right lobe volume, mean remnant liver volume, plus mean liver volume 2 mo after surgery in the donor and in the recipients, are reported in Table 3.

Mean value of donor liver volume was restored to 98% of the preoperative mean volume within 2 mo of surgery in the recipient and to 69% of the preoperative mean volume in the donor.

There was an 18% difference (P = 0.0001) between CT-scan-calculated right lobe donor mean volume (954.67) and right lobe weight mean value (784.56) on the back table.

There were no differences in distribution of anatomical variations in the groups of complicated and uncomplicated RHLD (Table 4). In addition, there were no differences between the complicated and uncomplicated RHLD regarding the baseline and post regeneration mean value of calculated liver volumes (Table 5).

All patients returned to their own activity after this perioperative period.

Donor safety has to be the first priority during the entire process of living-related transplantation, from the first day of evaluation through the entire follow-up period.

Therefore, an accurate and comprehensive step-by-step work-up protocol for donor evaluation has been designed in our center in order to ensure donor safety and, additionally, to confirm that the donor is capable of providing a suitable graft for the recipient.

In our experience, use of routine liver biopsy, though not generally accepted in all centers, allowed the exclusion of potential donors who otherwise would have been considered fit to donate based on other tests[20].

On the other hand, the biopsy allowed us to enroll donors who were anti-hepatitis B core positive.

Moreover, the routine use of liver biopsy as a screening tool in the living donor work-up allowed us to explore more safely the very common problem of steatosis.

The usefulness of steatotic livers depends on the percentage of fat, as livers with moderate to severe steatosis decrease graft and patient survival (with an additional unpredictable risk for liver donor regeneration). A BMI of > 30 may reliably predict a higher degree of steatosis in most donors. In order to enlarge the pool of living donor livers, but also to improve post-transplant outcomes, we made an attempt to lower the percentage of steatosis, rather than to turn down such overweight donors, by applying a short-term treatment of diet and exercise in all living-donor candidates with hepatic steatosis. After RHLD, no such donors experienced life-threatening complications or died. No long-term clinical impairment of treated donors has been observed and, after donation, all of them have returned to previous activity.

A strategy of careful evaluation of the living donor performed by an interdisciplinary team cannot be overemphasized.

A wide range of living donor complication rates are reported in the literature, with an estimated risk of mortality and morbidity after RHLD of 0.4% and 35%, respectively.

Overall, the complication rates range from 0% to 67%, with an overall crude complication rate of 31%[21]. The literature has reported 11 deaths, and 2 liver transplants in donors who have undergone RHLD. Additionally, one donor is in a persistent vegetative state after donation[22].

Organ shortage is a dramatic problem which can be limited by the rational use of ALRLT. So, based on our previous experience with liver resection[2] and use of partial livers from deceased donors[23], we began the living-related liver transplant program. Moreover, our partnership with one of the most active living-related liver transplant programs in the world[24] has allowed us to gain experience rapidly in this controversial field of surgery.

In our series, 30.6% of living donors developed a complication in the perioperative period, this not different from data recently reported in the literature[24]. In this group, RHLD with complications, there was no major incidence of anatomic variants, or difference in terms of liver regeneration after surgery, when compared with patients who did not develop any complications.

Additionally, our data regarding CT-scan-calculated liver volume confirmed that volumetric imaging may overestimate the actual liver volume[24].

Biliary complications (9.33%) were the most common complications after RHLD in our series, though no patients had to undergo repeated laparotomy for this reason. In two cases, after the failure of the endoscopic treatment, we were able to resolve the biliary leak due to a combined “rendezvous” procedure between endoscopist and interventional radiologist, who were able to pass an internal external transhepatic biliary drainage.

None of the 75 live donors in this series, regardless of their post-operative course, manifested any regrets about live donation.

In conclusion, this study reports the largest Italian experience with RHLD, focused on perioperative complications and on donor safety, which must be the first priority in right-lobe living-related donation.

Strict donor selection, detailed informed consent validated by the Italian law, together with a growing volume of cases performed every year, have allowed us to safely perform right hepatectomies for living donation in our center.

The need to define, categorize and record complications when healthy individuals, such as living donors, undergo a major surgical procedure like a right hepatectomy, reflects the need for prompt and detailed reports of complications arising in this particular category of patient.

Perioperative complications and post resection liver regeneration are not influenced by anatomic variations or patient demographic.